Are We Neglecting Nutrition in UK Medical Training? A Quantitative Analysis of Nutrition-Related Education in Postgraduate Medical Training Curriculums.

Suboptimal nutrition is a major cause of morbidity and mortality in the United Kingdom (UK). Although patients cite physicians as trusted information sources on diet and weight loss, studies suggest that the management of nutrition-related disorders is hindered by insufficient medical education and training. Objectives of this study were to: (1) Quantify nutrition-related learning objectives (NLOs) in UK postgraduate medical training curriculums and assess variation across specialties; (2) assess inclusion of nutrition-related modules; (3) assess the extent to which NLOs are knowledge-, skill-, or behaviour-based, and in which Good Medical Practice (GMP) Domain(s) they fall. 43 current postgraduate curriculums, approved by the General Medical Council (GMC) and representing a spectrum of patient-facing training pathways in the UK, were included. NLOs were identified using four keywords: 'nutrition', 'diet', 'obesity', and 'lifestyle'. Where a keyword was used in a titled section followed by a number of objectives, this was designated as a 'module'. Where possible, NLOs were coded with the information to address objective 3. A median of 15 NLOs (mean 24) were identified per curriculum. Eleven specialties (25.6%) had five or less NLOs identified, including General Practice. Surgical curriculums had a higher number of NLOs compared with medical (median 30 and 8.5, respectively), as well as a higher inclusion rate of nutrition-related modules (100% of curriculums versus 34.4%, respectively). 52.9% of NLOs were knowledge-based, 34.9% skill-based, and 12.2% behaviour-based. The most common GMP Domain assigned to NLOs was Domain 1: Knowledge, Skills and Performance (53.0%), followed by Domain 2: Safety and Quality (20.6%), 3: Communication, Partnership and Teamwork (18.7%), and 4: Maintaining Trust (7.7%). This study demonstrates considerable variability in the number of nutrition-related learning objectives in UK postgraduate medical training. As insufficient nutrition education and training may underlie inadequate doctor-patient discussions, the results of this analysis suggest a need for further evaluation of nutrition-related competencies in postgraduate training.

Nutritional Quality of Lunches Served in South East England Hospital Staff Canteens.

Worksite canteens generally are characterized by obesogenic environments, which offer access to energy-dense foods and sugar-sweetened beverages rather than nutrient-rich food. This study assessed the nutritional quality of hot lunches offered in National Health Service (NHS) hospital staff canteens: 35 side dishes and 112 meals were purchased from 8 NHS hospital staff canteens. The meals were analyzed for portion size, energy, protein, total fat, saturated fatty acids (SFAs), salt, and the sodium to potassium ratio. The vegetarian and meat-based lunch meals served in the hospital staff canteens tended to be high in energy, total fat, saturated fatty acids, and salt: 40%, 59% and 67% of meat meals and 34%, 43%, and 80% of vegetarian meals were assigned the red traffic light label for total fat, salt, and SFAs per portion, respectively. Similar types of meals, but served in different hospitals, varied considerably in their nutritional quality. The consumption of some lunch meals could provide more than 50% of recommended total fat, SFAs, and salt for both men and women and daily energy for women. The majority of analyzed lunch meals were characterized by an unfavorable nutrient profile, and regular consumption of such meals may increase the risk of noncommunicable diseases.

In Vitro Iron Bioavailability of Brazilian Food-Based by-Products.

Background: Iron deficiency is a public health problem in many low- and middle-income countries. Introduction of agro-industrial food by-products, as additional source of nutrients, could help alleviate this micronutrient deficiency, provide alternative sources of nutrients and calories in developed countries, and be a partial solution for disposal of agro-industry by-products. Methods: The aim of this study was to determine iron bioavailability of 5 by-products from Brazilian agro-industry (peels from cucumber, pumpkin, and jackfruit, cupuaçu seed peel, and rice bran), using the in vitro digestion/ Caco-2 cell model; with Caco-2 cell ferritin formation as a surrogate marker of iron bioavailability. Total and dialyzable Fe, macronutrients, the concentrations of iron-uptake inhibitors (phytic acid, tannins, fiber) and their correlation with iron bioavailability were also evaluated. Results: The iron content of all by-products was high, but the concentration of iron and predicted bioavailability were not related. Rice bran and cupuaçu seed peel had the highest amount of phytic acid and tannins, and lowest iron bioavailability. Cucumber peels alone, and with added extrinsic Fe, and pumpkin peels with extrinsic added iron, had the highest iron bioavailability. Conclusion: The results suggest that cucumber and pumpkin peel could be valuable alternative sources of bioavailable Fe to reduce iron deficiency in at-risk populations.

In vitro assessment of iron availability from commercial Young Child Formulae supplemented with prebiotics.

PURPOSE: Iron is essential for development and growth in young children; unfortunately, iron deficiency (ID) is a significant public health problem in this population. Young Child Formulae (YCF), milk-derived products fortified with iron and ascorbic acid (AA, an enhancer of iron absorption) may be good sources of iron to help prevent ID. Furthermore, some YCF are supplemented with prebiotics, non-digestible carbohydrates suggested to enhance iron bioavailability. The aim of our study was to evaluate iron bioavailability of YCF relative to prebiotic and AA concentrations. We hypothesised that YCF with the highest levels of prebiotics and AA would have the most bioavailable iron. METHODS: We used the in vitro digestion/Caco-2 cell model to measure iron bioavailability from 4 commercially available YCF with approximately equal amounts of iron, but varying amounts of: AA and the prebiotics fructo- and galacto-oligosaccharides. Caco-2 cell ferritin formation was used as a surrogate marker for iron bioavailability. RESULTS: The YCF with the highest concentration of prebiotics and AA had the highest iron bioavailability; conversely, the YCF with the lowest concentration of prebiotics and AA had the lowest. After the addition of exogenous prebiotics, so that all tested YCF had equivalent amounts, there was no longer a significant difference between YCF iron bioavailability. CONCLUSION: Our results suggest that ascorbic acid and prebiotics in YCF improve iron bioavailability. Ensuring that iron is delivered in a bioavailable form would improve the nutritional benefits of YCF in relation to ID/IDA amongst young children; therefore, further exploration of our findings in vivo is warranted.

Older Adults' Beliefs, Knowledge and Preferences for Achieving Healthy Vitamin D Status: A Narrative Review.

Autonomy and mobility are, in many cases, key elements underlying positive ageing. Vitamin D (vitD) is essential to maintaining musculoskeletal health and hence mobility; ensuring adequate vitD status is important in positive ageing. However, vitD deficiency persists in ~10-30% of older adults in the Western world. The aim of this review was to explore older adult vitD beliefs, knowledge and preferences, in order to identify means to prevent vitD deficiency respectful of older peoples' autonomy. Academic search-engines were used to explore the research literature with the keywords: vitamin D; older adults; preferences; knowledge; practices; beliefs. 22 recent studies were identified; although the majority of older people knew of vitD, knowledge about increased fall risk secondary to deficiency was limited and knowledge did not always correlate with adequate intake or status. There was evidence of confusion regarding vitD food sources, sun-exposure and health benefits, and although General Practitioners were trusted information sources they often did not discuss vitD with patients. Preferences varied significantly depending on geographic location, ethnicity, socioeconomic status, education and cultural factors; overall, older people wanted more clear information about vitD. In conclusion, older people have a relatively high awareness of vitD, however, knowledge may be inaccurate and low in those most at risk, and knowledge of deficiency-associated fall risk is under-recognised. Furthermore, studies specifically addressing older adult preferences are lacking; an understanding of preferences, integrated into public health guidelines and implementation strategies, is key not only to decreasing the risk of vitamin D deficiency but also to enabling autonomy in older adults.

Effects of Supplementation with Beef or Whey Protein Versus Carbohydrate in Master Triathletes.

OBJECTIVE: The present study compares the effect of ingesting hydrolyzed beef protein, whey protein, and carbohydrate on performance, body composition (via plethysmography), muscular thickness, and blood indices of health, including ferritin concentrations, following a 10-week intervention program. METHODS: After being randomly assigned to one of the following groups-beef, whey, or carbohydrate-24 master-age (35-60 years old) male triathletes (n = 8 per treatment) ingested 20 g of supplement mixed with plain water once a day (immediately after training or before breakfast). All measurements were performed pre- and postinterventions. RESULTS: Only beef significantly reduced body mass (p = 0.021) along with a trend to preserve or increase thigh muscle mass (34.1 ± 6.1 vs 35.5 ± 7.4 mm). Both whey (38.4 ± 3.8 vs 36.9 ± 2.8 mm) and carbohydrate (36.0 ± 4.8 vs 34.1 ± 4.4 mm) interventions demonstrated a significantly (p < 0.05) decreased vastus medialis thickness Additionally, the beef condition produced a significant (p < 0.05) increase in ferritin concentrations (117 ± 78.3 vs 150.5 ± 82.8 ng/mL). No such changes were observed for the whey (149.1 ± 92.1 vs 138.5 ± 77.7 ng/mL) and carbohydrate (149.0 ± 41.3 vs 150.0 ± 48.1 ng/mL) groups. Furthermore, ferritin changes in the beef group were higher than the modification observed in whey (p < 0.001) and carbohydrate (p = 0.025) groups. No differences were found between whey and carbohydrate conditions (p = 0.223). No further changes were observed. CONCLUSION: Ingesting a hydrolyzed beef protein beverage after workout or before breakfast (nontraining days) can be effective in preserving thigh muscle mass and in improving iron status in male master-age triathletes.

Nutrient and Total Polyphenol Contents of Dark Green Leafy Vegetables, and Estimation of Their Iron Bioaccessibility Using the In Vitro Digestion/Caco-2 Cell Model.

Dark green leafy vegetables (DGLVs) are considered as important sources of iron and vitamin A. However, iron concentration may not indicate bioaccessibility. The objectives of this study were to compare the nutrient content and iron bioaccessibility of five sweet potato cultivars, including three orange-fleshed types, with other commonly consumed DGLVs in Ghana: cocoyam, corchorus, baobab, kenaf and moringa, using the in vitro digestion/Caco-2 cell model. Moringa had the highest numbers of iron absorption enhancers on an "as-would-be-eaten" basis, ß-carotene (14169 µg/100 g; p < 0.05) and ascorbic acid (46.30 mg/100 g; p < 0.001), and the best iron bioaccessibility (10.28 ng ferritin/mg protein). Baobab and an orange-fleshed sweet potato with purplish young leaves had a lower iron bioaccessibility (6.51 and 6.76 ng ferritin/mg protein, respectively) compared with that of moringa, although these three greens contained similar (p > 0.05) iron (averaging 4.18 mg/100 g) and ß-carotene levels. The ascorbic acid concentration of 25.50 mg/100 g in the cooked baobab did not enhance the iron bioaccessibility. Baobab and the orange-fleshed sweet potato with purplish young leaves contained the highest levels of total polyphenols (1646.75 and 506.95 mg Gallic Acid Equivalents/100 g, respectively; p < 0.001). This suggests that iron bioaccessibility in greens cannot be inferred based on the mineral concentration. Based on the similarity of the iron bioaccessibility of the sweet potato leaves and cocoyam leaf (a widely-promoted "nutritious" DGLV in Ghana), the former greens have an added advantage of increasing the dietary intake of provitamin A.

Calcium to phosphorus ratio, essential elements and vitamin D content of infant foods in the UK: Possible implications for bone health.

Adequate intake of calcium and phosphorus in the appropriate ratio of 1-2:1 (Ca:P), in addition to magnesium and vitamin D, is vital for bone health and development of infants. In this feasibility study, the ratio of Ca:P in conjunction with vitamin D and other essential elements (Cu, Fe, K, Mg, Na, and Zn) in a range of commercial infant food products in the UK was investigated. The elemental analysis was carried out using inductively coupled plasma optical emission spectrometry, and vitamin D levels were determined using an enzyme-linked immunosorbent assay. The quantitative data were further evaluated, based on a standardised menu, to measure the total daily intake of an infant aged 7-12 months against the Reference Nutrient Intake. The results from the study show that the Ca:P ratio of the infant's total dietary intake was within the recommended range at 1.49:1. However, the level of intake for each of the nutrients analyzed, with the exception of sodium, was found to be above the Reference Nutrient Intake, which warrants further investigation in relation to both micronutrient interactions and in situations where the intake of fortified infant formula milk is compromised. Finally, as the study is the first to include consumption of infant snack products, the level of total calorie intake was also calculated in order to assess the total daily estimated energy intake; the results indicate that energy intakes exceed recommendations by 42%, which may have implications for obesity.

Iron Bioavailability and Provitamin A from Sweet Potato- and Cereal-Based Complementary Foods.

Iron and vitamin A deficiencies in childhood are public health problems in the developing world. Introduction of cereal-based complementary foods, that are often poor sources of both vitamin A and bioavailable iron, increases the risk of deficiency in young children. Alternative foods with higher levels of vitamin A and bioavailable iron could help alleviate these micronutrient deficiencies. The objective of this study was to compare iron bioavailability of ß-carotene-rich sweet potato-based complementary foods (orange-flesh based sweet potato (OFSP) ComFa and cream-flesh sweet potato based (CFSP) ComFa with a household cereal-based complementary food (Weanimix) and a commercial cereal (Cerelac®), using the in vitro digestion/Caco-2 cell model. Iron bioavailability relative to total iron, concentrations of iron-uptake inhibitors (fibre, phytates, and polyphenols), and enhancers (ascorbic acid, ß-carotene and fructose) was also evaluated. All foods contained similar amounts of iron, but bioavailability varied: Cerelac® had the highest, followed by OFSP ComFa and Weanimix, which had equivalent bioavailable iron; CFSP ComFa had the lowest bioavailability. The high iron bioavailability from Cerelac® was associated with the highest levels of ascorbic acid, and the lowest levels of inhibitors; polyphenols appeared to limit sweet potato-based food iron bioavailability. Taken together, the results do not support that CFSP- and OFSP ComFa are better sources of bioavailable iron compared with non-commercial/household cereal-based weaning foods; however, they may be a good source of provitamin A in the form of ß-carotene.

Iron bioavailability from commercially available iron supplements.

PURPOSE: Iron deficiency anaemia (IDA) is a global public health problem. Treatment with the standard of care ferrous iron salts may be poorly tolerated, leading to non-compliance and ineffective correction of IDA. Employing supplements with higher bioavailability might permit lower doses of iron to be used with fewer side effects, thus improving treatment efficacy. Here, we compared the iron bioavailability of ferrous sulphate tablets with alternative commercial iron products, including three liquid-based supplements. METHODS: Iron bioavailability was measured using Caco-2 cells with ferritin formation as a surrogate marker for iron uptake. Statistical analysis was performed using one-way ANOVA followed by either Dunnett's or Tukey's multiple comparisons tests. RESULTS: Spatone Apple(®) (a naturally iron-rich mineral water with added ascorbate) and Iron Vital F(®) (a synthetic liquid iron supplement) had the highest iron bioavailability. There was no statistical difference between iron uptake from ferrous sulphate tablets, Spatone(®) (naturally iron-rich mineral water alone) and Pregnacare Original(®) (a multimineral/multivitamin tablet). CONCLUSION: In our in vitro model, naturally iron-rich mineral waters and synthetic liquid iron formulations have equivalent or better bioavailability compared with ferrous iron sulphate tablets. If these results are confirmed in vivo, this would mean that at-risk groups of IDA could be offered a greater choice of more bioavailable and potentially better tolerated iron preparations.

Sugars increase non-heme iron bioavailability in human epithelial intestinal and liver cells.

Previous studies have suggested that sugars enhance iron bioavailability, possibly through either chelation or altering the oxidation state of the metal, however, results have been inconclusive. Sugar intake in the last 20 years has increased dramatically, and iron status disorders are significant public health problems worldwide; therefore understanding the nutritional implications of iron-sugar interactions is particularly relevant. In this study we measured the effects of sugars on non-heme iron bioavailability in human intestinal Caco-2 cells and HepG2 hepatoma cells using ferritin formation as a surrogate marker for iron uptake. The effect of sugars on iron oxidation state was examined by measuring ferrous iron formation in different sugar-iron solutions with a ferrozine-based assay. Fructose significantly increased iron-induced ferritin formation in both Caco-2 and HepG2 cells. In addition, high-fructose corn syrup (HFCS-55) increased Caco-2 cell iron-induced ferritin; these effects were negated by the addition of either tannic acid or phytic acid. Fructose combined with FeCl3 increased ferrozine-chelatable ferrous iron levels by approximately 300%. In conclusion, fructose increases iron bioavailability in human intestinal Caco-2 and HepG2 cells. Given the large amount of simple and rapidly digestible sugars in the modern diet their effects on iron bioavailability may have important patho-physiological consequences. Further studies are warranted to characterize these interactions.

Immunoendocrine responses of male spinal cord injured athletes to 1-hour self-paced exercise: pilot study.

This study examined the effect of a 1 h, self-paced handcycling time trial on blood leukocytes, mucosal immunity, and markers of stress in paraplegic athletes. Nine male paraplegic athletes (spinal injury level thoracic 4-lumbar 2) performed 1 h of handcycling exercise on a standard 400 m athletics track. Heart rate (HR) was measured continuously during exercise, and a retrospective rating of perceived exertion (RPE) was obtained immediately after. Venous blood and saliva samples were collected immediately before exercise (Pre-Ex), after exercise (End-Ex), and 1 h postexercise (1-h Post). The athletes completed mean +/- standard error of mean 22.4 +/- 1.1 km cycling at HR 165 +/- 2 beats/min, RPE 15 +/- 1, and blood lactate 7.9 +/- 2.5 mmol/L. Total leukocytes increased 72% and neutrophils increased 74% End-Ex; both remained elevated at 1-h Post (both p < 0.05). Lymphocytes increased 53% and natural killer cells increased 175% End-Ex (both p < 0.05), but returned to near baseline levels 1-h Post. Increases (p < 0.05) were observed End-Ex in alpha-amylase activity (p < 0.05), which returned to baseline at 1-h Post, but there was no significant change in saliva flow rate, salivary immunoglobulin A, or cortisol. These data confirm that 1 h of handcycling exercise elevated circulating leukocytes but had a minimal effect on mucosal immunity. These changes appear to be associated with alpha-amylase rather than cortisol.